Free Communication Screening for Children

This screening helps identify whether speech language therapy, coaching, or group support may be a helpful next step. It is not a diagnostic evaluation.

Parent/Caregiver Name*

Child's Name*

Child's age*

Email*

Which of the following concerns do you have about you child's communication? (Select all that apply)*

limited vocabulary for age

Difficulty combining words into sentences

My child doesn't speak

Frustration when trying to communicate

My child frequently throws tantrums/has meltdowns when I don't understand them.

Difficulty telling stories or answering questions

My child tries to talk, but I don't understand them.

My child repeats sounds, words or phrases and sometimes it seems like their words are getting "stuck"

My child struggles to follow directions that I feel like they should be able to follow.

My child has difficulties with eating or drinking.

Other

How often to unfamiliar listeners understand your child?*

Almost always

Sometimes

Rarely

Not Sure

Other

Do you have concerns about your child's social communication?*

Difficulty interacting with other children.

Trouble taking turns in games or conversation.

Difficulty staying on topic or changing topics.

Limited engagement or eye contact.

No social communication concerns

Other

Has your child ever received speech-language services?*

Yes, Currently on an IEP for speech or receiving private services

Yes, in the past

Not Sure

Other

Is there any other information that you would like us to know, or that will help our licensed SLP understand what is going on when reviewing this screening?

This is a screening, not an evaluation. If you continue to have concerns about your child's communication, we recommend that you reach out for a formal diagnostic evaluation to rule out communication concerns.

Wholistic Therapy LLC

405-260-5085

2415 W. Noble

Guthrie, OK 73044

wholistictherapyllc@gmail.com

Accessibility Statement

bottom of page